Provider Demographics
NPI:1003997628
Name:HOMINY COMMUNITY MEDICAL TRUST AUTHORITY
Entity Type:Organization
Organization Name:HOMINY COMMUNITY MEDICAL TRUST AUTHORITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-538-8278
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:HOMINY
Mailing Address - State:OK
Mailing Address - Zip Code:74035-0098
Mailing Address - Country:US
Mailing Address - Phone:800-538-8278
Mailing Address - Fax:580-628-2273
Practice Address - Street 1:505 N. EASTERN
Practice Address - Street 2:
Practice Address - City:HOMINY
Practice Address - State:OK
Practice Address - Zip Code:74035-1034
Practice Address - Country:US
Practice Address - Phone:800-538-8278
Practice Address - Fax:580-628-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKEMS4213416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100699680BMedicaid
OK100699680BMedicaid
OK736005260Medicare ID - Type Unspecified